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Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low...Shadab Ahmad
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Lower Mortality with Transradial PCI Compared to Transfemoral PCI in 21 000 Patients with Acute Myocardial Infarction - Results from the SCAAR Database
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Radial artery patency after transradial catheterization
1. Radial Artery Patency After
Transradial Catheterization
Mark A Kotowycz,MD , MBA , FRCPC
Vladimir Dzavik , MD , FRCPC ,FAHA
Presented by Piti Niyomsirivanich , MD.
Cardiovascular Fellowship Maharat nakhonratchasima hospital
3. Radial artery occlusion
• 1-10% of cases
• Usually clinically silent due to dual blood supply
• And usually overlooked > 50% doesn’t routinely access
• But once the artery occluded cannot be used as
– access site for the future catheterization
– as an arterial conduit for bypass surgery
4. Pathophysiology
• Thrombotic process
– reduced with anticoagulant
– radial artery thrombus
• (vascular ultrasound , angiography )
• Local endothelial injury after sheath insertion
• Cessation of blood flow
• Tend to occure early after transradial catheterization
50% spontaneous recanalization within 1-3 months
5. Negative effects radial structural and function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG
6. Negative effects radial structural and
function
• Structure
– 67% intimal tear
– 36% medial dissections immediately
– Small lumen area in repeated more than the 1st time
• Intimal hyperplasia
• Intima-media thickness
• Function
– Decrease response to NTG
repeated radial access site failure
reduced graft patency in patient undergoing bypass
surgery with radial artery conduits.
8. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study
9.
10.
11. • efficacy and safety
– transradial versus femoral approach
Radial % Femoral
%
HR 95% CI P
Major Vascular
Access site
Complications
1.4 3.7 0.37 0.27-0.52 < 0.0001
Other Definition of Major Bleeding
TIMI Non-
CABG Major
bleeding
0.5 0.5 1.0 0.53-1.09 1.00
Acuity Non-
CABG Major
bleeding
1.9 4.5 4.5 0.32-0.57 < 0.0001
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
RIVAL Study
12. In summary From RIVAL Study
• no difference in rates of composite
– Death.
– myocardial infarction.
– Stroke.
– major bleeding between access strategies.
• But
– radial access decreased major vascular
complications.
The Lancet, Volume 377, Issue 9775, Pages 1409 - 1420, 23 April 2011
13. Physical examination
• Weak or absent radial pulse.
• But may have a palpable pulse from collateral
ulnar (retrograde filling)
• Thus : Dx of RAO should not depend on
presence or absence pulse.
14. Natural History
71 % improved
20 % diffuse stenosis
60 % partial or complete
recanalization
Long term (3 months)
American Journal of Cardiology
Volume 83, Issue 2 , Pages 180-186, 15 January 1999
N=162 routine Ultrasound at Day 2 after transradial catheterization
15. Natural History
Catheterization and Cardiovascular Diagnosis
Volume 40, Issue 2, pages 156–158, February 1997
N=563 with a normal Allen test evaluate by U/S
RAO 5.3%
No complication
47% spontaneous
recanalization
follow-up (1 months)
17. Assessing Dual Hand Circulation
• Plethysomography and pulse oximetry
(barbeau test)
No single case observed of hand ischemia in 7000 patients
18. Assessing Dual Hand Circulation
• Duplex ultrasounography (most accurate way)
19. Predictors of RAO
• Diameter of the sheath
• Postprocedure compression time
• Presence of anterograde flow during
hemostasis
• Use of anticoagulation
20. Sheath size
• Oversized of Sheath
– vascular remodeling
– Thrombosis
250 patients
under going PCI
Pretreated
with NO
Journal of the Society for Cardiac Angiography & Interventions [1999, 46(2):173-178]
6F or larger inserted
S-A ratio > 1 RAO 13%
S-A ratio < 1 RAO 4%
(P=0.01)
21. Sheath size
171 patients
under going PCI
6 F Sheath
5 F Sheath
RAO 1.1% in 5F group
RAO 5.9% in 6F group
NAUSICA trial (Ongoing)
patients under
going PCI
Randomized
4F Sheath
6F Sheath
RAO
1-month follow-up
Catheterization and Cardiovascular Interventions
Volume 57, Issue 2, pages 172–176, October 2002
P = 0.08
NCT00815997
22. Predict radial artery size ??
• Associations between radial artery diameter
– BW , Ht. Surface area weak correlation and
less predictable
J INVASIVE CARDIOL 2013;25(7):353-357
23.
24. Options to minimized the risks of RAO
• 5F system can be used in most patients.
• New Sheathless hydrophillic guiding catheters
– (external diameter of 5F sheath while 6.5F internal
diameter)
• Larger guides with an external diameter of 6F
sheath that have and internal diameter
equivalent to a 7F guide
25. Patent Hemostasis
• Compressible
• But too aggressive compression
– no flow state thrombosis
• Predictor of RAO
– Absence of anterograde flow during hemostasis
28. Anticoagulation
• Minimize the risk of the RAO
• Based on observational data because of no
RCT.
• Heparin (Current practice 2000-5000 U of
heparin)
29. Anticoagulant
0
10
20
30
40
50
60
70
80
Spaulding et al. (p<0.05)
N=415
Bernad et al. (p = 0.17)
N=465
no anticoagulant
2000 U heparin
5000 U heparin
71%
24%
4.3% 4.9%
2.9%
Cathet Cardiovasc Diagn. 1996 Dec;39(4):365-70.
Am J Cardiol. 2011 Jun 1;107(11):1698-701
31. • But Heparin add on Bivalirudin remains
unclear. (need further investigation)
32. Treatment
• Relatively asymptomatic.
• Observation
• Recanalization
– relieve ischemic symptoms
– to save the artery for future procedure
– Anterograde or Retrograde
• Aspiration after wiring
33. Conclusions
• Occurs in 1-10%
• Mechanism : Thrombosis
• Strategies for minimized RAO
– Small Sheaths or Sheathless
– Non occlusive hemostasis
– anticoagulation